Tobacco cessation

25 important questions on Tobacco cessation

The 5 A's model for treating tobacco use and dependence

Ask about use
Advise to quit
Assess readiness to quit
Assist in quit attempt
Arrange follow-up   

Pack year smoking history

Cigarette packs/day x number of years smoked

Preferred 1st line: pregnant, adolescents, "light smokers"

Behavioral counseling
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Smoking women >/= 35 years, should not take what?

Estrogen containing PO contraceptives due to risk of CV events

What vaccines do smokers aged 19-64 years, specifically need?

Pneumococcal and flu

1st line nicotine replacement therapy (NRT)

Combo therapy with long acting patch and short acting NRT (gum or lozenge)
[more effective than monotherapy] 

Rx NRT side effects

Nicotine inhaler (Nicotrol): mouth and throat irritation
Nicotine nasal spray (Nicotrol NS): nasal irritation

Should the nicotine patch (nicoderm cq) be removed before MRI?

Yes.

Nicotine gum and lozenge counseling

4mg can delay weight gain, do not drink/eat 15 min before or during use

Nicotine patch (nicoderm cq) start dose is based on what?

Number of cigarettes per day
(1 pack = 20 cigarettes) 

Nicotine gum/lozenge start dose is based on what?

Timing of 1st cigarette smoked after waking up

Nicotine gum/lozenge starting dose

>/= 9 pieces/day in first 6 weeks

How does bupropion work?

Blocks neuronal reuptake of DA and/or NE

Does bupropion need to be tapered when discontinued?

No.

Bupropion SR (zyban) dosing

150 mg QAM for 3 days, then 150 mg BID
Max: 300 mg/day

Bupropion warnings/side effects

Neuropsychiatric events, dry mouth, insomnia, tremors, weight loss, tachycardia, agitation, constipation

What can be done to decrease insomnia with bupropion?

Take 1st dose after waking up and 2nd dose 8 hours later

The most effective monotherapy for smoking cessation because it decreases withdrawal symptoms and rewards with smoking

Varencicline

When should varencicline be started? Does it need tapered when discontinued?

1 week before quit date.It does not need to be tapered when stopped.

How should varencicline be tapered up?

Days 1-3: 0.5 mg daily
Days 4-7: 0.5 mg BID
Day 8 (quit date): 1 mg BID 

Varencicline warnings/side effects

Neuropsychiatric events (depression), nausea, insomnia, vivid dreams, headache

How to decrease nausea with varencicline?

Take after eating with full glass of water

Varencicline is more effective than what?
Varencicline + nicotine patch is more effective than what? 

Bupropion
Varencicline alone 

If patient has weight gain, use?

Gum, lozenge, or bupropion (delays weight gain)

Nicotine patch counseling

Wear for 24 hours. Rotate site (do not apply to same site for at least 1 week). Never cut or wear more than one at a time. 

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